OPEN ACCESS
Research Article
Human & Veterinary Medicine
International Journal of the Bioflux Society
Effects of an aquatic therapy program on vital
capacity, quality of life and physical activity index
in children with cerebral palsy
Dragoş Adrian Maniu, 2Emese Agnes Maniu, 3Ileana Benga
1
Department of Physiotherapy and Special Motoric Skills, Faculty of Physical Education and Sports, Babes-Bolyai University, ClujNapoca, Romania; 2 Special High School for Visually Challenged, Cluj Napoca, Romania; 3 Department of Pediatric Neurology, “Iuliu
Haţieganu” Medicine and Pharmacy University of Cluj-Napoca, Romania.
1
Abstract. The aim of this paper is to track the aspects and results of applying an aquatic therapy intervention program adapted and integrated
in the treatment of neuromotor reeducation of children with cerebral palsy on gross motor function, spasticity and range of motion. Material
and methods: The aquatic therapy program had a duration of 6 months, 2 weekly sessions. The average duration of a session was 45 minutes.
The water temperature was 36°C. Besides the aquatic therapy sessions the children participate in 2 physical therapy sessions which were included in the rehabilitation program of the institutions they belonged to. Twenty-four children diagnosed with cerebral palsy have participated
in this study. The average age was 12.5±2.7 years.The assessment methods used were: Physical Activity Index is calculated by multiplying
physical activity frequency, intensity and duration. Spirometry: The following device was used in order to assess vital capacity: MIR Spirobank
II Spirometer, S/N 000912. Results: After the use of the aquatic therapy program, results have been statistically significant for physical activity index scores p<0.001. Baseline percentage of the maximum physical activity index score was 16.8% and the final percentage of the maximum physical activity index score was 68%. KINDLR - Questionnaire for measuring quality of life in children and adolescents. The scores of
the questionnaire assessing quality of life in children and adolescents, KINDLR, show statistically significant increases (p<0.001), where we
can observe a significant increase from a mean score of 67.3 ± 6.9 to a mean score of 96±4.1. At the end of the 6-month aquatic therapy program, the values for vital capacity have shown a statistically significant increase, p<0.001. The mean value of baseline vital capacity was of
2.2±0.7, the mean value of final vital capacity was of 3.4±1.1. The values for vital capacity increased by 56.7% when compared to baseline
values. Conclusion: The aquatic therapy program along with the classic rehabilitation program is a factor which influences these parameters.
Key Words: aquatic therapy program, physical activity index, quality of life, vital capacity.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Corresponding Author: D. A. Maniu, asoru2003@yahoo.com
Introduction
Swimming and aquatic exercises are often recommended for children with disabilities, since they are recognized as part of paramedical treatment programs (Huberman 1976, Ruoti et al 1997).
The specific advantageous features of aquatic activities for children with disabilities include: (a) water buoyancy, which favors
the initiation of movement even if the neuromuscular system is
unable to move against gravity, (b) increased viscosity of water,
which provides gradual resistance (braking force) and together
with the amplitude of movement makes very demanding exercises almost impossible, (c) heat transfer in the water is much
faster than in the air, water reaching 32ºC or more decreases
spasticity and leads to the lack of involuntary movement, (d)
hydrostatic pressure provides extensive stimulation of exteroceptors and proprioceptors, increased pressure on the lungs and
other internal organs, as well as pressure on the respiratory muscles. These are assumed to improve coordination, breathing and
associated functions such as feeding and speech (Harris 1978;
Peganoff 1984; Broach & Dattilo 1996).
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Despite the enthusiasm for the therapeutic effects of aquatic exercises, very little information has been published in this field
(Hutzler et al 1998).
Rothman (1978) observed a significant decrease of respiratory
functions in children with cerebral palsy compared to children
without disabilities (37-38% below normal values).
The respiratory system is deeply affected when the body is immersed in water to the chest. An effect is chest compression
by water, as well as the change in lung function, increased respiratory muscle effort and the change in respiratory dynamics.
Vital capacity decreases by 7-9% when the body is immersed
in water up to the neck as compared to when it is immersed to
the xiphoid process. Part of this decrease is due to increased
blood volume in the thoracic cavity, part is due to the hydrostatic force of water which resists inspiratory muscles (Hong
et al 1996; Agostoni et al 1996).
Inspiratory muscle weakness is an important component of
many chronic diseases. Given the accommodation of respiratory functions in an environment that causes significant changes
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in respiratory function, immersion can be used for respiratory
training and rehabilitation (Mangelsdorff et al 2001).
Aquatic therapy can be very useful in the management of patients with neuromuscular disability of the respiratory system,
such as spinal cord injuries and muscular dystrophy (Adams &
Chandler 1974; Koessler et al 2001; Topin et al 2002 Wanke
et al 1994).
Aquatic physical therapy combined with land physical therapy can improve respiratory functions in children with cerebral
palsy (Hutzler et al 1998).
It was established that both children and adults with cerebral
palsy have low levels of physical activity compared to people
without disabilities. This sedentary lifestyle affects their health
and physical fitness (Damiano 2006). People with cerebral palsy
are prone to the risk of developing a form of depression, anxiety
and increased stress, low self-esteem and motivation, as well as
withdrawal from social life.
Interventions based on therapeutic exercises have been shown
to have a positive effect on social life, self-esteem, depression
and self-confidence in terms of involvement in physical activities (Shapiro & Martin 2010).
The aquatic environment particularly promotes social interaction and a persistent level of acceptance. Some have attributed
this additional benefit to the opportunity provided by water in
order to initiate multiple social interactions with teachers and
peers (Getz et al 2006).
The World Health Organization Quality of Life Assessment
Group defines quality of life as “an individual’s perception of
their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards and concerns” (WHOQOL 1996). Shelley et al
2008 stated that this is a multidimensional system that evaluates
an individual’s sense of well-being in many areas of their lives.
There was a conceptual separation between quality of life and
function, a task which was partly carried out by the World
Health Organization (WHOQOL 1996) and other researchers
in the early 1990s, defining quality of life as the “assessment
missing in health care” (Fallowfield 1990).
The definition of quality of life aimed, on the one hand, to be
used as a measure of assessment in research, and on the other
hand, from a broader perspective, to extend the way in which
health was measured beyond conventional indicators, such as
mortality and morbidity. Quality of life goes beyond the purpose
of the scientific objective to eradicate the disease, for a more
balanced and humanistic approach of the individual’s well-being (WHOQOL 1996).
This paper aims to observe the effects of a 6-month aquatic
therapy program associated to a physical therapy program on
vital capacity, quality of life and physical activity index in children with cerebral palsy.
The Gross Motor Function Classification System (GMFCS)
The degree of mobility of children and teenagers at home, at
school and in the community can be best described using the expanded and revised Gross Motor Function Classification System
(GMFCS – E&R). This classification system covers a wide range
from level 1, where individuals work at an advanced level, being able or having the potential to walk without restrictions,
to level 5, for individuals very limited in their ability to move
themselves around even with the use of assistive technology.
Materials and method
Spirometry
The following device was used in order to assess vital capacity: MIR Spirobank II Spirometer, S/N 000912.
The respiratory function tests were administered by the same
technician after the child had been habituated to the spirometer
for 10 minutes.
The study included 24 children diagnosed with different clinical
forms of cerebral palsy enrolled in two of the special schools
in Cluj County. The age of the participants in the study was between 8 and 16 years.
Inclusion criteria were the following: diagnosis, ability to follow simple verbal instructions. None of the children has ever
attended aquatic therapeutic intervention sessions.
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Physical Activity Index
Physical activity index is calculated by multiplying physical
activity frequency, intensity and duration.
To generate positive effects in terms of health, a physical activity must be performed frequently, must last enough time (not
less than 20-30 minutes, but not much more than the exercising level or phase) and must engage as many muscle groups as
possible, at an appropriate level of intensity.
KINDLR - Questionnaire for measuring quality of life in
children and adolescents
KINDLR is a generic instrument for assessing health-related
quality of life (HRQoL) in children and adolescents aged 3 years
and older. The original version of the questionnaire, KINDL,
was developed by Prof. Monika Bullinger in 1994. Prof. Ulrike
Ravens-Sieberer & Monika Bullinger revised KINDL and developed KINDLR in 1998.
KINDLR is a short and flexible questionnaire, providing 24 items.
There are three different versions of the instrument, suitable
for different age groups and stages of disease development.
KINDLR can be used for children and adolescents aged between
3 and 17 years. In addition, each version of the questionnaire
can be completed by both children and adolescents, as well as
by their parents.
The factorial structure of the questionnaire consists of six factors:
1. Physical well-being (e.g.: I felt nauseous; I felt active and
full of life);
2. Emotional well-being (e.g.: I was happy and in a good mood);
3. Self-esteem (e.g.: I was proud of myself)
4. Family (e.g.: I get along well with my parents)
5. Social relationships (e.g.: I feel different from other children)
6. School (e.g.: I worry about my future)
Calculate a total score of the scale by summing the partial
scores of the six factors. A better health status is determined by
a higher total score. To make comparisons, the total score can
be converted into a mean total score for the entire questionnaire.
The clinical usefulness of the questionnaire: KindlR can be used
to assess the effect of different therapeutic procedures (with
baseline and end of treatment assessments) (Ravens & Sieberer
2001; Ravens & Sieberer 2003).
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Table 1. Main characteristics of the participants
No. of participants
Age of participants
Gender of
participants
Clinical forms
24
Average 12.5 ± 2.7 years
Boys
18
Girls
6
Spastic cerebral palsy
19
- Paraparesis
5
- Tetraparesis
10
- Hemiparesis
right
2
left
2
Dyskinetic cerebral palsy
4
Ataxic cerebral palsy
1
No. of participants
GMFCS Level
Level I Independent walk, restrictions of the advanced ability of movement
Level II Walking without aid, restrictions of the walk in the outdoor environment or on
accidental ground
Level III Walking with assistive mobile devices, restrictions of the movement outdoor or in
the community
Level IV Diminished mobility, the child is transported or needs other means of transport
outdoors or in the community
Level V Independent mobility is severely restricted even with technical support
Aquatic therapy program
It is a useful strategy for teaching swimming for people with
neuromotor disorders. The program uses the principles of fluid
mechanics in order to enable subjects to achieve stability and
controlled movement in the water.
The aquatic therapy program was conducted over a period of 6
months, consisting of two weekly sessions. Every session was
45 minutes long. Water temperature was 36 ̊C.
The program aims to achieve water independence for children
with CP. In order to maintain water balance, it is necessary to
adapt to the mechanical changes occurring in this environment.
These adaptations are the result of a psycho-sensory-motor learning process that enables the individual to learn how to maintain
balance in an unstable environment. Once balance (stability) is
established, movement can be initiated and controlled (Lambec
& Stanant 2000, Lambec & Stanant 2001).
Statistical analysis
The SPSS statistics software version 20 was used for statistical analysis. Data were classified as categorical or quantitative.
Categorical variables were described using frequency and percentage, and quantitative variables were described using the mean
and standard deviation or the median. Kolmogorov-Smirnov
test was used to check the normality of the quantitative data.
To determine whether there were changes between conjugate
variables we used the Wilcoxon signed-rank test or the test for
marginal homogeneity, depending on the situation. General linear
models for repeated measures were used to check the influence
of a parameter on the variation in the values of a conjugate variable. Statistical significance was set at a threshold value of 0.05.
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0
10
8
2
4
Results
Physical Activity Index
After the use of the aquatic therapy program, results have been
statistically significant for physical activity index scores p<0.001.
Table 2. Physical activity index scores
Mean
IAF initial total
IAF final total
% initial of
max.
% final of max.
N
Standard
deviation
3
9.7
16.8
68
24
24
16.8%
24
3
68%
24
9.7
Table 2 presents the total baseline score and the total final score
for physical activity index, where we can observe a significant
increase from an average score of 16.8±3 to an average score
of 68±9.7. A significant increase of 51% compared to baseline
assessment scores could be noticed. Baseline percentage of the
maximum physical activity index score was 16.8% and the final percentage of the maximum physical activity index score
was 68%.
For GMFCS level 2, the mean baseline score was 18 and the
mean final score was 70.4 ± 8. The results show high statistically
significant differences, p<0.001. There was a 52.4% progress
from the baseline assessment for GMFCS level 2.
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Table 3. Physical activity index mean scores and standard deviation according to the Gross Motor Function Classification
System for cerebral palsy (GMFCS)
IAF scores
GMFCS II Mean
St. deviation
GMFCS III mean
St. deviation
GMFCS IV-V
Mean
St. deviation
Initial
Initial Final
%
18
0
18
0
70.4
8.2
72
8.5
13.5
58.6
4.9
8.2
18%
18%
Final
%
P
70.4% <0.001
72%
<0.001
13.5% 58.6% <0.001
For GMFCS level 3, the mean baseline score was 18 and the
mean final score was 72±8.5. The results show high statistically significant differences, p<0.001. There was a 54% progress
from the baseline assessment for GMFCS level 3.
For GMFCS level 4-5, the mean baseline score was 13.5±4.9
and the mean final score was 58.6±8.2. The results show high
statistically significant differences, p<0.001. There was a 45.1%
progress from the baseline assessment for GMFCS level 4-5.
Table 4. Scores of the questionnaire assessing quality of life in
children and adolescents – KINDLR
KINDLR - Questionnaire for measuring quality of life in
children and adolescents
The scores of the questionnaire assessing quality of life in children and adolescents, KINDLR, show statistically significant
increases, p<0.001.
Table 4. shows the total baseline score and the total final score
of the questionnaire scores assessing quality of life in children
and adolescents, KINDLR, where we can observe a significant increase from a mean score of 67.3±6.9 to a mean score
of 96±4.1. There is a significant 23.7% increase compared to
baseline assessment scores. There was a 56% baseline maximum score of the questionnaire assessing quality of life in children and adolescents (KINDLR) and a 79.8% final maximum
score of the questionnaire assessing quality of life in children
and adolescents (KINDLR).
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St. deviation
67.3
24
6.9
96
24
4.1
56
24
5.8
79.8
24
3.4
Table 5. KINDLR scores - the mean and standard deviation
based on the GMFCS
KINDLR
Scores
GMFCS II
mean
St. deviation
GMFCS III
mean
St. deviation
St. deviation
Fig. 1. Evolution of physical activity index scores depending
on GMFCS level before and after the program
N
Total KINDLR
initial
Total KINDLR
final
initial % of
max.
Final % of max.
GMFCS IV-V
mean
•
Mean
Initial Final
68.6
95.5
8.8
4.14
67.6
96.3
6.8
4.1
64.8
96.5
2
4.6
Initial
%
Final
%
57.1%
79.5% <0.001
56.3%
80.3% <0.001
54%
80.4% <0.001
P
For GMFCS level 2, the mean baseline score was 68.6±8.8 and
the mean final score was 95.5±4.1. The results show high statistically significant differences, p<0.001. There was a 22.4%
progress from baseline for GMFCS level 2. Baseline maximum
score of KINDLR questionnaire was 57.1% and final maximum
score of KINDLR questionnaire was 79.5%.
For GMFCS level 3, the mean baseline score was 67.6±6.8 and
the mean final score was 96.3±4.1. The results show high statistically significant differences, p<0.001. There was a 23.9%
progress from baseline assessment for GMFCS level 3. Baseline
maximum score of KINDLR questionnaire was 56.3% and final
maximum score of KINDLR questionnaire was 80.3%.
For GMFCS level 4-5, the mean baseline score was 64.8±2 and
the mean final score was 96.5±4.6. The results show high statistically significant differences, p<0.001. There was a 26.3%
progress from baseline assessment for GMFCS level 4-5.
The highest values were obtained for SELF-ESTEEM and
SOCIAL RELATIONS.
There was a 35.2% increase from baseline values for SELFESTEEM, from a 38.9% maximum possible score to a 74.1%
maximum possible score, p<0.001.
There was a 35.6% increase from baseline values for SOCIAL
RELATIONS, from a 45.2% maximum possible score to an
80.8% maximum possible score, p<0.001.
There was a 29.3% increase from baseline assessment for
PHYSICAL WELL-BEING, from a 54.6% maximum possible
score to an 83.95% maximum possible score, p<0.001.
There was a 29.5% increase from baseline assessment for
EMOTIONAL WELL-BEING, from a 51% maximum possible
score to a 79.6% maximum possible score, p<0.001.
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Table 6. Values for vital capacity – the mean and standard deviation according to the GMFCS
Vital capacity - liters
GMFCS II mean
st. deviation
GMFCS III mean
st. deviation
GMFCS IV-V mean
st. deviation
↑
Initial Final compared
P
with initial
2.4
3.9
<0.001
0.6
0.8
57.3%
1.8
2.8
<0.004
0.6
1.1
51.3%
2.2
3.6
59.7% <0.001
0.9
1.4
Fig. 2. Evolution of KINDLR questionnaire scores based on the
GMFCS level before and after the program
There was a 6.8% increase from baseline assessment for FAMILY,
from an 80.6% maximum possible score to an 87.50% maximum possible score, p<0.001.
There was a 7.9% increase from baseline assessment for SCHOOL,
from a 66.2% maximum possible score to a 74.1% maximum
possible score, p<0.001.
Vital capacity
At the end of the 6-month aquatic therapy program, the values for vital capacity have shown a statistically significant increase, p<0.001.
Table 6. shows the baseline and the final values for vital capacity assessed in liters, as well as the percentage of the predicted
value for vital capacity. The mean value of baseline vital capacity was of 2.2±0.7 with a minimum value of 1.1 liters and a
maximum value of 4 liters, the mean value of final vital capac.
ity was of 3.482±1.1, with a minimum value of 1.9 liters and a
maximum value of 6.2 liters.
The mean baseline values represented 66.1% of the predicted
vital capacity, with a minimum value of 38% and a maximum
value of 91%. The mean final assessment reported 99.2% values for the predicted vital capacity, with a minimum value of
70% and a maximum value of 134%.
The values recorded were 36.3% lower than the expected values related to age, gender and height of subjects.
The values for vital capacity increased by 56.7% when compared to baseline values.
For GMFCS level 2, there was a mean baseline value of 2.4±0.638
and a mean final value of 3.9±0.8. The results show high statistically significant differences, p<0.001.
For GMFCS level 3, there was a mean baseline value of 1.8±
0.6 and a mean final value of 2.8±1.1. The results show high
statistically significant differences, p=0.004.
For GMFCS level 4-5, there was a mean baseline value of 2.2
±0.94and a mean final value of 3.6±1.4. The results show high
statistically significant differences, p<0.002.
The most significant increase in the values for vital capacity
was recorded in subjects with GMFCS level 2.
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Fig. 3. Evolution of vital capacity values based on the GMFCS
level before and after the program
Discussions
Rothman (1978) states the presence of a significantly reduced
respiratory function in children with cerebral palsy compared
to those without disabilities (37-38% below normal values).
In our study, the mean value recorded was 36.38% lower than
the expected values related to age, gender and height of subjects.
Rothaman studied the effects of breathing exercises (for example, force exercises) on vital capacity and maximum expiratory
volume in children with cerebral palsy. Five children made up
the control group with no intervention, and five children made
up the experimental group with 5-7 minute sessions of training
exercises for inspiratory and expiratory muscles.
The results showed a 31% difference between the experimental
group and the control group during the final assessment.
Lee et al (2013) investigated the effects of respiratory training
on pulmonary function in children with cerebral palsy. Twentytwo children randomly divided into 2 groups (control group
and experimental group) attended three weekly sessions of full
recovery. The experimental group participated in respiratory
training sessions. The program lasted for 4 weeks. Significant
results regarding respiratory function were observed in the control group, where forced vital capacity recorded a 50% increase
from baseline assessments.
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Table 7. Values for vital capacity – liters
Predicted Vital capacity Vital capacity
% Of vital
vital capacity values – initial values – finale capacity from
liters
-liters
- liters
predicted initial
N
% Of vital
capacity from
predicted final
% of increase
compared with
baseline %
24
24
24
24
24
24
Mean
3.5
2.2
3.4
66.1%
99.4%
56.7%
Standard
deviation
1.1
0.7
1.1
15.5
14
22.4
Minimum
1.9
1.1
1.9
38%
70%
17.5%
Maximum
5.8
4
6.2
91%
134%
89.9%
Hutzler et al (1997) described the effects of an aquatic program
on breathing in children with cerebral palsy. Fifteen children
were part of the experimental group, participating in two weekly
30 minute-long sessions of individualized aquatic exercises. The
average age of the children was 5.2±0.8 years. Thirteen children
were part of the control group, undergoing a Bobath neuro-developmental treatment program. The program lasted six months,
period during which the children continued their other regular
activities at kindergarten and school. Results show a 68% improvement in vital capacity compared to baseline assessment
for the group participating in the aquatic therapy program and
a 23% increase for the experimental group participating in respiratory sessions performed by the neuro-developmental therapist. The authors conclude that further research is needed in this
field, conducted on a larger number of participants.
Hutzler et al (1998) studied the effects of a movement and
swimming program on vital capacity. The study included 46
participants (23 in the control group, 23 in the experimental
group) with cerebral palsy aged 5-7 years. The experimental
group participated in two sessions of aquatic exercises and one
group gym session, both on a weekly basis, while the control
group participated in four weekly sessions of Bobath therapy.
Hutzler reported improvements in vital capacity in the experimental group. There was a 65% increase from baseline assessment in the values for vital capacity in the experimental group.
In our study, the values for vital capacity increased by 56.7%
when compared to baseline values.
Hutzler observed that the values for vital capacity in children
with CP were 23-35% lower during baseline assessment than
predicted values calculated according to age, weight and height
for healthy children.
The authors concluded that the aquatic therapy program can improve respiratory functions. They recommend including these
water sessions in therapeutic programs for children with CP.
The effects of these aquatic therapy programs on social function, behavior and body awareness have been the focus of several research studies (Getz et al 2007; Ozer et al 2007; Aidar
et al 2008).
Getz et al (2007) compared the effects of a water exercise program with those of a land exercise program. Their goal was to
assess the effects on social function, skills perception (physical
and cognitive skills) and social acceptance in 22 children with
CP. Twelve of the children had participated in the water exercise
program and 10 in the land exercise program. Social function
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was measured by using the Pediatric Evaluation of Disability
Inventory (PEDI). Perceived skills and social function were
measured using the Pictorial Scale developed for children with
CP. Their results showed statistically significant differences for
social acceptance between the group undergoing land exercises
and the group undergoing water exercises (t=2.26, p<0.035).
There were increased scores for social acceptance in the group
of patients participating in the water exercise program and no
significant difference between the groups in terms of perceived
physical skills. “The aquatic environment, especially buoyancy, allows children to be more active and to initiate more social interaction with their instructors and with other children”
(Getz et al 2007).
A 14-week swimming program was applied by Ozer et al (2007)
to assess its effects on social skills, behavior and body awareness (somatognosia) problems in 13 children with CP, aged
5-10 years. They found that the swimming program improved
body awareness, but had no significant effect on behavior or
social skills.
Another study on the effect of water activities on social function
was performed by Aidar et al (2008), consisting of 21 children
with CP. Social function was assessed using PEDI and motor
function was assessed using the Manual Ability Classification
System (MACS). The results showed a positive change in motor function and social function. Aidar et al (2008) found a correlation between self-esteem improvement and functional independence improvement.
Aidar et al (2008) have extrapolated that water exercise and
increased motor function lead to an improvement in physical
function which in turn improves social function, suggesting an
increase in independence.
In our study, there was a significant increase in SELF-ESTEEM,
represented by a 35.2% increase from baseline values in the
KINDLR questionnaire.
McClung (1997), quoted in Shapiro and Martin (2010), found
that adults with physical disabilities participating in recreational
activities have improved their self-esteem and their confidence
in the ability to perform physical activities. Young people with
physical disabilities have obtained psycho-social benefits from
conducting physical activities, including in terms of friendship, joy, empowerment and decrease in depression (Shapiro
& Martin 2010).
Dorval et al (1996) evaluated the effect of a swimming program
on self-esteem and functional independence in 20 adolescents
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with CP, and observed statistically significant improvements after intervention, the results being maintained even nine months
after the intervention.
Deckler et al (2013) studied the effects of a 6-week swimming
program on quality of life in 7 children with a mean age of 10.2
years, suffering from cerebral palsy. They used the questionnaire
for quality of life of people with PC (CPQOL) which measures
the influence of an intervention on quality of life, the version
for parents. The results showed a 3.7% improvement for participation and physical health when comparing the baseline and
the final assessment and a 4.2% increase when comparing the
final assessment and the assessment performed 3 weeks after
program completion. There was a 1.2% increase in movement
scores between the baseline and the final assessments and a
4.6% increase between the baseline assessment and the assessment performed 3 weeks after program completion. Scores for
access to services increased by 20%, but they decreased during
the assessment performed 3 weeks after program completion.
Pain and impact of disability revealed a 19.4% improvement
between the baseline and the final assessments and a 14.9%
increase between the baseline assessment and the assessment
performed 3 weeks after program completion. Family health increased by 4.3% between the baseline and the final assessment
and by 7.3% 3 weeks after program completion. Five of the
seven quality of life scales for people with CP have improved
and almost all results were maintained during the assessment
performed 3 weeks after program completion. In our study,
quality of life scores assessing quality of life in children and
adolescents - KINDLR, indicated a significant increase from a
mean score of 67.3±6.9 to a mean score of 96±4.1.
The highest values were obtained for SELF-ESTEEM and
SOCIAL RELATIONS scores.
In 2006, Damiano stated that both children and adults with
cerebral palsy have low levels of physical activity compared
to people without disabilities. This sedentary lifestyle affects
their health and physical fitness (Damiano 2006).
Fragala et al (2010) conducted a study whose purpose was to
describe an aquatic therapy program, to analyze it and to determine its strengths and weaknesses from the parents’ perception
perspective. Sixteen children aged 6-12 years were included in
this study. The program lasted 14 weeks and consisted of swimming, water games and water force exercises.
Following parental surveys, results showed that participants in
the study have increased the number of days when children were
involved in physical activity compared to the existing situation
before applying the program. After program completion, children
continued practicing physical activities. Parents declared that
after the program, the 16 children continued performing physical activities at least 5 days a week, consisting of 60 minutes
of moderate or vigorous activity, compared to 3 days of physical activity performed before the program (Fragala et al 2010).
In our study, following the use of the questionnaire for physical activity index there is a significant increase of 51% compared to baseline assessment scores. Baseline maximum score
for physical activity index was 16.8% and final maximum score
for physical activity index was 68%. The subjects included in
our study have greatly improved the frequency and the intensity and duration of physical exercises compared to activities
performed prior to the implementation of the aquatic program.
Volume 5 | Issue 3
Conclusions
This paper aims to observe the effects of a 6-month aquatic
therapy program on vital capacity, quality of life and physical
activity index in children with cerebral palsy.
Study results showed statistically significant increases in the
values for vital capacity, in KINDLR questionnaire scores assessing quality of life, and in physical activity index.
Aquatic exercise programs can be beneficial types of therapy, a
pleasant alternative for children and adolescents suffering from
cerebral palsy, including for those with significant movement
restrictions for whom physical activities on land are difficult,
thus enabling patients with CP to improve the duration, intensity and frequency of physical exercise practice.
The two aquatic therapy sessions added to the already existing
physical activities in the children’s program, have increased
physical activity index by increasing the intensity, frequency
and duration of physical exercise.
The combination between aquatic therapy and land-based physical therapy can represent a factor which improves respiratory
function in children with cerebral palsy. Aquatic therapy may
be useful in the management of patients with cerebral palsy for
the rehabilitation of respiratory deficiency. The effects of an
aquatic therapy program on vital capacity are positive, leading
to improved vital capacity.
After applying an aquatic therapy program we observed a positive effect on physical well-being, emotional well-being, selfesteem, family, social relationships, and school indices, with
the highest values obtained for self-esteem and social relationships. The aquatic environment mainly promotes social interaction and a persistent level of acceptance. This additional benefit
can be attributed to the fact that water provides opportunities
to initiate multiple social interactions with teachers and peers.
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Authors
•Dragoş A. Maniu, Department of Physiotherapy and Special
Motoric Skills, Faculty of Physical Education and Sports,
Babes-Bolyai University, 7th Pandurilor Street, 400376, ClujNapoca, Cluj, Romania, EU, email: asoru2003@yahoo.com
•Emese A. Maniu, Special High School for Visually Challenged,
31st Calea Dorobantilor Street, 400117, Cluj Napoca, Cluj,
Romania, EU
•Ileana Benga, Department of Pediatric Neurology, “Iuliu
Haţieganu” Medicine and Pharmacy University of Cluj-Napoca,
43rd Victor Babes Street, 400012, Romania, EU
Maniu, D. A., Maniu, E. A., Benga, I., 2013. Effects of an aquatic therapy program
Citation on vital capacity, quality of life and physical activity index in children with cerebral
palsy. HVM Bioflux 5(3):117-124.
Editor Ştefan C. Vesa
Received 29 October 2013
Accepted 21 November 2013
Published Online 22 November 2013
Funding None reported
Conflicts/
Competing None reported
Interests
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